Jacobi Ambulatory Care Service Medical Consultation: An Overview Lori A. Lemberg, MD Fall 2012

JacobiAmbulatory Care Service

Medical Consultation: An Overview

Lori A. Lemberg, MD

Fall 2012

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Yes, this is Medical Consult, How can I help you?

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Learning Objectives

• Function of the Medical Consultant• Goldman’s “Ten Commandments”• Surgical Considerations• Anesthesia Considerations• Appropriate History and Evaluation of Patient• ACC-AHA Guidelines

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Function of the Medical Consultant

to offer an opinion on diagnosis or management

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Goldman’s Ten Commandments for Effective Consultation

1. Determine the Question

2. Establish Urgency

3. Look for Yourself

4. Be as Brief as Appropriate

5. Be Specific

6. Provide Contingency Plans

7. Honor Thy Turf

8. Teach …With Tact

9. Talk is Cheap…and Effective

10. Follow UpGoldman et al, Arch Int Med 1983; 143: 1753

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1. Determine the Question

Ask the requesting service to be as specific as possible

Clarify verbally if the question(s) are unclear

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3. Look for Yourself

• Emergency, Urgent, Elective• See the patient within 24 hours

2. Establish Urgency

• Review pertinent history and physical exam

• Make an independent judgment

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4. Be as Brief as Appropriate

• Do not recopy the history and physical• Highlight important points

5. Be Specific• The more detailed the suggestions the better• Spell out dosing, timing of meds• Less is more

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6. Provide Contingency Plans• Anticipate problems

7. Honor Thy Turf

• Do not step on other’s toes• Remember your position as consultant

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8. Teach with Tact

• Talk with the primary physician or service about your findings and recommendations

• Discuss disagreements • Bring the attendings to the table if necessary

9. Talk is Cheap and Effective

• Encourage collegial relations

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10. Follow-Up

• Interval as appropriate to the case• Improves compliance with recommendations• Tell services you are signing off• Provide specific outpatient follow-up plan

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Factors Improving Compliance with Recommendations

• Consult within 24 hours• More than two follow-up notes• Verbal contact with referring MD• Limited number of recommendations (<5) • Recommendations related to “central reason”

of consult

Kammerer, Gross, Medical Consultation

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Factors Improving Compliance with Recommendations

• Definitiveness of recommendation• “Crucial” recommendation• Details spelled out• Medication/treatment vs. diagnostic• Severely ill patient

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Pre Operative Consultation

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Pre Operative Consultation Why?

• Elucidate patient’s risks and benefits of surgery

• Improve risk by optimizing medical condition• Anticipate perioperative and postoperative

complications

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Risk of Surgery

INHERENT RISKS OF PROCEDURE

High: Emergency procedures, Major Vascular, Craniotomy

Medium: Orthopedic, Prostate, Abdominal, Thoracic

Low: Breast, Plastic

Very Low: Cataract, Dental, Endoscopic

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Surgeon Specific Risk

Hospital Specific Risk

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Anesthesia

GENERAL• depresses cardiac function• airway control, but reduced lung volumes

SPINAL or EPIDURAL• vasodilates• avoid with aortic stenosis

No difference in CV events!

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When do things go wrong?

• Mortality Related to Surgery

10-15% during induction

30-40% during surgery

45-60% post-operative• Peak for Myocardial Infarction

Day 0, 1, 2 days postoperatively

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Induction

Catecholamine surge

Blood pressure lability

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Post Operative State

• Metabolic demands• Pain• Fluid Shifts• Catecholamine surges• CHF, Coronary ischemia• Atelectasis, VQ mismatch, Pneumonia• DVT• Immobilization

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If the inherent risk of surgery is low, can I make an impact?

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Medical Considerations for Surgery

• Cardiovascular: CAD, CHF, HTN, Arrhythmias, Valvular heart disease

• Hematologic: Bleeding, DVT risk• Pulmonary: COPD, Asthma, Smoking• Renal: Renal insufficiency• Endocrine: Diabetes, Thyroid, Adrenal

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Medical Considerations for Surgery

• Hepatic: Cirrhosis, Hepatitis• Habits: Alcohol, Drugs• Medications• Endocarditis prophylaxis• Pregnancy• Geriatric patients

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History

Include:• Previous surgery or complications• Bleeding• Functional capacity / Exercise tolerance• Medications• Allergies• Substance Use • Family History (bleeding, malignant hyperthermia)

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Exam

• Vitals• General Exam• Mental Status

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Laboratories

Controversial, Low predictive value

CBC Anemia? Baseline?

Chemistries K+? BUN/Cr?

PT, PTT, Bleeding Time not predictive

EKG for higher risk or older patients?

CXR doubtful

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Cardiovascular Risk Assessment

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Higher Risk Features

Goldman et al• Age > 70 5 pts• MI < 6 months 10 pts• S3 or JVD 11 pts• Important valvular AS 3 pts• Rhythm other than sinus 5 pts• > 5 PVCs per minute 5 pts

NEJM 1977; 297:845

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Goldman continued

• Poor general medical status 3 pts• Intraperitoneal, 3 pts

intrathoracic or aortic surgery• Emergency surgery 4 pts

Total 53 pts

Medium 13-25 pts 12% complications

High Risk >25 pts 56% complications

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Lee et alRisk Factors in Multivariate Analysis of 4315 Patients

• High Risk Surgery• Ischemic Heart Disease• Congestive Heart Failure• History of TIA or Stroke• Insulin Therapy for Diabetes• Pre Op Creatinine > 2.0

Circulation 1999:100: 1043

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Lee et al

0.4 0.9

6.6

11

0

2

4

6

8

10

12

Rate of Cardiac Complications (MI, PulmEdema, VFib, Cardiac Arrest, Complete Heart

Block)

O factors1 factor2 factors3 factors

Circulation 1999:100: 1043

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Table 1. Applying classification of recommendations and level of evidence.

Fleisher L A et al. Circulation 2007;116:e418-e500

Copyright © American Heart Association

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American College of Cardiology American Heart AssociationRevised 2002/2007 Guidelines

MAJOR CLINICAL PREDICTORS• Unstable angina, Recent MI• Decompensated CHF• Significant Arrhythmias (high grade AV block,

symptomatic ventricular arrhythmias, SVT uncontrolled• Severe valvular disease

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INTERMEDIATE CLINICAL PREDICTORS

•Mild angina•Past history of CHF•Prior MI•Diabetes

ACC-AHA 2002/2007 Guidelines

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ACC-AHA 2002/2007 Guidelines

MINOR CLINICAL PREDICTORS• Age

• ECG (LVH, LBBB, ST-T changes)

• Low functional capacity (< 4 mets)

• Rhythm other than sinus

• Uncontrolled hypertension

• Past history of stroke